Skin Care Worksheet
Skin type Date:
Dry:_________________ Name:
Oily:_________________ Address:
Mature:______________ Tel:
Other:_______________
Skin Concerns: Explain:
Acne:_____________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Rosacea:___________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Other:_____________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Medical Treatment Received:___________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________ All Medications Taken:_________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name and Telephone of Dermatologist or Doctor:___________________________________
___________________________________________________________________________
___________________________________________________________________________
PLEASE FILL OUT AND RETURN TO ME